How is conversion disorder diagnosed and treated?

Conversion Disorder: Diagnosis and Treatment

Conversion disorder is diagnosed through positive clinical signs demonstrating internal inconsistency and symptom variability with attention, not by ruling out other conditions, and is treated primarily with psychotherapy—specifically Cognitive Behavioral Therapy—not medication. 1

Diagnostic Approach

Making a Positive Diagnosis

The diagnosis of conversion disorder must be based on positive clinical findings rather than simply excluding organic disease 2. This represents a fundamental shift from historical practice and is critical for effective patient engagement.

Key diagnostic features include:

• Internal inconsistency of symptoms: Resolution or reduced severity during spontaneous conversation, when attention is diverted, or during automatic functions 2
• Suggestibility: Symptoms become more prominent when being discussed or examined 2
• Distractibility: Symptoms worsen with attention and improve with distraction, often developing after injury, illness, or psychological distress 1
• Inefficient movement patterns: When weakness is the complaint, speech and swallowing fatigue in the direction of muscle hyperfunction with struggle behaviors including overmouthing, eye blinking, facial contortions, and excessive effort 2

Essential Differential Diagnosis

Before confirming conversion disorder, you must systematically exclude neurological conditions through comprehensive evaluation 1:

• Guillain-Barré syndrome and variants 1
• Multiple sclerosis and demyelinating disorders 1
• Myasthenia gravis 1
• Stroke or vascular events 1
• Metabolic disorders 1
• Inflammatory or infectious nervous system conditions 1

Important caveat: While misdiagnosis rates have decreased, conversion symptoms can be superimposed on organic disease, making detection more challenging 3. Stroke mimics including conversion disorder were identified in approximately 3% of patients treated with fibrinolytics, though without increased treatment risk 2.

Treatment Algorithm

Step 1: Explain the Diagnosis (Therapeutic in Itself)

The explanation is the foundation of treatment and may have therapeutic value on its own 2. Your approach must:

1. Take the problem seriously and acknowledge symptoms are real and involuntary 2, 1
2. Explain this is a positive diagnosis based on specific clinical signs, not a diagnosis of exclusion or something mysterious 2
3. Demonstrate the positive clinical signs you observed during examination 2
4. Provide written materials and resources 2

Critical pitfall to avoid: A dismissive approach that fails to acknowledge the involuntary nature of symptoms will damage the therapeutic alliance and undermine treatment 1, 4.

Step 2: Initiate Psychotherapy as First-Line Treatment

Psychotherapy, not medication, is the definitive first-line treatment 1. There is no evidence supporting significant benefit from pharmacotherapy specifically for functional symptoms 1, 5.

Cognitive Behavioral Therapy (CBT) is the evidence-based psychotherapeutic approach:

• Duration: 12-22 weekly sessions 1
• Key components: Psychoeducation and formulation, exposure with response prevention and/or behavioral experiments, and relapse prevention 1
• Engagement strategy: Motivational interviewing techniques are helpful at therapy initiation to increase engagement 1

Step 3: Consider Intensive Therapy Schedule

Clinical experience suggests intensive therapy with sessions several times per week may be most successful in helping patients regain normal function, inhibit abnormal movements or struggle behaviors, and maintain treatment gains 2.

Many patients achieve improvement or even elimination of symptoms during the initial consultation, though this doesn't necessarily mean full resolution 2. This early improvement is very encouraging and should be highlighted to the patient.

Step 4: Implement Symptom-Specific Techniques

For functional tremor specifically:

• Rhythm modification: Superimpose alternative voluntary rhythms on the existing tremor and gradually slow all movement to complete rest 4
• Entrainment techniques: Use the unaffected limb to dictate a new rhythm that entrains the tremor to stillness 4
• Music incorporation: Introduce music to dictate a rhythm for the patient to follow, overriding the tremor pattern 4

For functional communication, swallowing, and voice disorders:

• Symptomatic behavioral work integrated with counseling 2
• Demonstration of symptom variability during natural automatic functions 2

Step 5: Address Comorbidities Only

Medication should be limited to treating comorbid psychiatric conditions (such as depression or anxiety) rather than targeting conversion symptoms directly 5. Unlike essential tremor or other neurological conditions, pharmacotherapy has no role in treating the functional symptoms themselves 4.

Critical Treatment Pitfalls to Avoid

Do not reinforce illness behavior through:

• Excessive focus on symptoms 1, 4
• Providing unnecessary adaptive equipment or aids (these are generally unhelpful in rehabilitation for functional disorders) 4, 5
• If aids are necessary, use them as short-term solutions only with a minimalist approach 4

Do not take a dismissive approach that:

• Fails to acknowledge the involuntary nature of symptoms 1, 4
• Suggests the patient is "faking" or can simply "stop" the symptoms 2

Do not rely on pharmacotherapy as primary treatment, as there is no evidence supporting benefit for functional symptoms themselves 1, 5

Expected Outcomes and Follow-Up

Most patients referred with functional disorders can benefit substantially or dramatically from speech and language therapy or appropriate psychotherapy, sometimes rapidly 2. The key is maintaining the therapeutic framework established during diagnosis explanation while providing structured behavioral interventions and psychological support.